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Physiotherapy for Children with Functional Constipation: A Pragmatic Randomized Controlled Trial in Primary Care
Jojanneke J G T van Summeren1, Gea A Holtman1, Boudewijn J Kollen1
1Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center, Groningen, the Netherlands.
Insights
Adding physiotherapy to conventional treatment did not improve outcomes for children with functional constipation. While parents reported better symptom improvement with physiotherapy, it did not lead to statistically significant long-term success rates.
Area of Science:
- Pediatric Gastroenterology
- Physical Therapy
- Primary Care Medicine
Background:
- Functional constipation is a common condition in children.
- Conventional treatment includes toilet training, dietary advice, and laxatives.
- Dyssynergic defecation may contribute to constipation in some children.
Purpose of the Study:
- To evaluate the effectiveness of physiotherapy combined with conventional treatment versus conventional treatment alone for pediatric functional constipation.
- To assess treatment success, defined by symptom resolution and absence of laxative use, over an 8-month period.
Main Methods:
- A pragmatic randomized controlled trial involving 234 children (aged 4-17 years) diagnosed with functional constipation.
- Participants were assigned to receive either conventional treatment plus physiotherapy or conventional treatment alone.
- Outcomes measured included treatment success (Rome III criteria without laxatives), absence of constipation regardless of laxative use, and perceived treatment effect.
Main Results:
- Adding physiotherapy did not significantly improve the primary outcome of treatment success compared to conventional treatment alone (adjusted relative risk [aRR] 0.80).
- At 4 months, physiotherapy showed lower success rates, but by 8 months, success rates were similar (42% vs. 41%).
- Parent-reported global symptom improvement was significantly higher in the physiotherapy group (aRR 1.40).
Conclusions:
- Physiotherapy is not recommended as a universal treatment for all children with functional constipation in primary care settings.
- While some parents perceived greater symptom improvement with physiotherapy, it did not translate to statistically significant improvements in constipation resolution.
- Further research may explore specific subgroups of children who might benefit from physiotherapy.
Objective:
To determine the effectiveness of physiotherapy plus conventional treatment compared with conventional treatment alone for the treatment of functional constipation in children age 4-17 years in primary care.
Study Design:
Pragmatic randomized controlled trial with 8 months follow-up. Primary care physicians recruited children diagnosed with functional constipation (n = 234), and pediatricians recruited newly referred children with a diagnosis of functional constipation (n = 11). Conventional treatment comprised toilet training, nutritional advice, and laxative prescribing, whereas physiotherapy focused on resolving dyssynergic defecation. The primary outcome was treatment success over 8 months, defined as the absence of functional constipation (Rome III criteria) without laxative use. Secondary outcomes included the absence of functional constipation irrespective of continuation of laxative use and global perceived treatment effect.
Results:
Children were allocated to conventional treatment plus physiotherapy or conventional treatment alone (67 per group), mean (SD) age was 7.6 (3.5) years. Results of longitudinal analyses in the intention-to-treat population showed that the treatment success percentage was not statistically improved by adding physiotherapy to conventional treatment (adjusted relative risk [aRR] 0.80, 95% CI 0.44-1.30). At 4 months, fewer children receiving physiotherapy had treatment success (17%) than children receiving conventional treatment alone (28%), but this had equalized by 8 months (42% and 41%, respectively). The percentage of children without functional constipation, irrespective of continuation of laxative use, was not statistically different between groups over 8 months (aRR 1.12, 95% CI 0.82-1.34). Notably, parents reported significantly more global symptom improvement after physiotherapy than after conventional treatment (aRR 1.40; 95% CI 1.00-1.73).
Conclusions:
We find no evidence to recommend physiotherapy for all children with functional constipation in primary care.
Trial Registration:
Netherlands Trial Registry: NTR4797.
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